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my first cadaver [blog]

Pediatrics probably has more in common with veterinary medicine than any other specialty. A good number of patients are drooling, non-verbal, squirmy little monsters belonging to caring, anxious adults acting as interpreter and advocate. There will be whining. There could be biting. There will be lots of praise. (“Good boy!” “Good girl!”) Possibly a puddle. And, if appropriate, a treat at the end.

When kids get a little bigger, as you will hear, it gets a bit more complicated. Once these curious little creatures start becoming mobile anything can happen and they aren’t always that eager (or able) to talk about it. So what does it take to make it in the world of monkey badges, nervous parents, and superhero bandaids? The mind of great detective? A master of telepathy? The patience of a saint? A second-grader’s sense of humor? A heart as big as the moon?

In this episode, we will hear from Doctors Eli Freiman, Lauren Appell, Scott Bader, and Nick Rowan about their experiences working with children and the people who love them, and also get some perspective from three-year-old patient, Jesse Gellert, who has his own story to tell.

(Photo: Jesse Gellert, the monkey in the crayon bucket. Snapshots taken by Andrea Gellert.)

This is the transcript of Episode 11 of the medical podcast My First Cadaver. Enjoy!

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FAITH AERYN: What do beads, boogies and bugs have in common? Pediatrics, of course! This is Episode 11 of My First Cadaver. I’m Faith Aeryn.

Over the course of our first season, we’ve delved into all things adult-medicine related. So for this episode, I wanted to explore one area of medicine in which being vulnerable and entirely human is both encouraged and essential; where it’s necessary for doctors to also work as mind-readers, interpreters, playmates and detectives.

Because kids are famous for putting things up their noses, in their ears, and swallowing things they shouldn’t — let’s start with Dr. Lauren Appell — a Pediatric resident and graduate of the University of Alabama School of Medicine.

DR. LAUREN APPELL: I was in the ER, and it said “foreign body in ear.” She was about nine years old, so she was actually able to communicate with me and tell me what happened. She was telling me that she was sleeping over at her grandmother’s and felt something fall into her ear, and she was wigging out because she could feel it moving. I thought, “Oh, shit, it’s going to be a bug.” Every time it moved, she’s flipping out. She can’t sit still on the bed, it was hard for me to […?...] anytime anything would touch her ear, she would just flip out. I mean I probably would, too, if something was crawling around in my ear. Very weird sensation. So I said, “Let’s take a look.” I looked and I could see the ear drum. Then I saw this black—almost like a leg. Then I pulled back a little bit more and I could visualize the body. I would drop the otoscope and say, “Oh, my god!” She was laughing at that point, she said, “Is there a bug in my ear?” I said, “There’s a roach in your ear! I’m sorry—let me pull myself together.” The mom was over there in hysterics, laughing because I was wigging as much as the patient was. In my vast eight months of being a pediatrician, I hadn’t seen a bug, but apparently that’s a pretty common thing that happens. I went back into the resident workroom and said, “Oh, my god! Oh, my god!” Everyone was like, “What?!” I said, “She has a roach in her ear! I think I’m going to vomit.” I don’t get like that. I’m not a squeamish person. I can handle any bodily fluid, but roaches are the one thing I would not have wanted to find in someone’s ear. So I go over to my attending to check out a patient with him, and I asked, “What do we do? How are we going to get it out?” He said to drown it, so we poured mineral oil in her ear and basically suffocated the roach. So we were trying to flush it out after that, but it just wasn’t coming out. So we let all the mineral oil run out and I went in and plucked it. It came out in one piece, and it was a nasty old cockroach. I said, “Hey, you want to see Eddie? Eddie’s deady!” I think she even asked to take it home, but I said, “Uh, better not.”

FA: [laughing] I’m dying over here. “Eddie’s deady?” That’s the greatest thing ever.LA: That’s what I kept calling him: Eddie the cockroach. Eddie’s deady!FA: Let’s go to Dr. Eli Freiman — a Pediatric resident and graduate of the University of Massachusetts Medical School.DR. ELI FREIMAN: I think my favorite stories are with young kids, toddlers who are just learning to speak, or young school-age kids, K, pre-K kids who say things that just catch their parents off-guard. Parents are used to being with their children every second of every day. When you’re a baby, when you’re a toddler, before you learn to walk, you are never out of your parents’ eyesight. Once kids get a little bit older and they learn to walk, they become a little more independent , there’s an increasing amount time every day, where the kids are not under direct supervision. That leads to some really funny situations where we’ll be in the clinic seeing patients, and one patient will be complaining of pain in his nose and mucus has been coming out of it for the past couple days, and the parent is like, “I don’t know what happened. He hasn’t been sick. I have no idea what’s been going on.” And the kid is just kind of quietly sitting there for about five minutes while I’m talking with the parents, and eventually the patient will just look up at me and say, “I put a Lego up my nose.” And the parent will just immediately—you can see it in their eyes—their eyes go wide, their head will immediately turn to their child, and they say, “You did WHAT?” And the kid goes, “Yeah! I put a Lego up my nose. My older brother told me to.” This is a really funny situation; it’s an easily fixable problem. You go in, you pull it out, the kid’s fine. But the shock on that parent’s face when they realize, “Oh, my god, I now have a human being who is independent, living at my household. Who knows what they’re going to get into?” It’s that paradigm shift that is really funny and somewhat terrifying to witness.

FA: What better way to hear what Pediatricians deal with when trying to get the whole story, than by hearing it directly from a patient? It’s my pleasure to introduce Jesse Gellert — a three year old who recently had to have a toy robot sprocket removed from his nostril.

JESSE GELLERT: Do you know why I did it?FA: No, why did you do it?JG: I did it… I did it… I didn’t… I didn't… I did it…I didn’t.. do it… I wanted to do it. FA: You did?JG: Yeah, I did. I, the table, the table fell. FA: And that’s how Ricky the Robot lost that piece?JG: Yeah. FA: Oh, man. Poor Ricky. Oy! And when you had to go to the doctor, what did they have to do?JG: I was trying to climb the, the dresser.FA: Oh, you were? Oh, and that’s why he fell. Yep, that’ll happen.JG: I was standing on my table, and then it breaked and then, and then, and then the little piece of Ricky, little piece of Ricky—down.FA: On the floor? JG: Yeah.FA: And then you put it in your nose?JG: Yeah. Ricky died.FA: Ricky died? When he fell off the great big…JG: Yeah.ANDREA SCHULMAN GELLERT: We’re done with Ricky. Ricky is in the garbage.FA: Oh, no!ASG: Ricky is gone.JG: RICKY is gone.

LA: Kids really do the darnedest things. I’ve had a kid eat a quarter or something, and I go in and ask, “Did you eat something you weren’t supposed to?” And they’ll say, “Yes.” “And what did you eat?” “A coin.” They’re always really pleased with themselves.

EF: There are lots of kids with those stories. We admitted a child who came in with abdominal pain. You do a standard workup in the emergency department but we couldn’t figure out [the reason for the abdominal pain]. He ended up getting an X-ray, and sure enough, right in the middle of this kid’s intestine is what looked like a dime. The parents said, “Well, why’d you eat a dime?” The kid was like, “I don’t know. They’re shiny. What do you want me to do? I put it in my face and ate it.” The parents are like, how long am I going to be taking care of this kid’s poop for before I find out whether the dime is coming out or not. Everything in pediatrics is about poop. It’s amazing, the amount of times I walk into a room, have to look the parents square in the eye, and say, “What color was your child’s poop?” Was it green? That’s OK. Yellow? Still OK. Brown, totally OK. Red? Not OK. Black? I’d be concerned. The parents give me this bizarre look, and meanwhile the children — 6, 7, 8 year olds — are sitting up in the bed, looking at me like they can’t believe this is coming from an adult’s mouth. “Poop? I was told not to talk about that.” It gets even better as you get into the pre-teen and teenage years, when you have to say, “Look, this is super awkward. We ask really awkward questions, but you need to tell me about your poop. Yep, I want to know when, where, what, why, how, and that’s just how it is.” To be honest, that’s not even the worst question we have to ask parents. As a young, male pediatrician, I know way more about breastfeeding than I knew a year ago. It’s awkward at first to walk in and ask a mom who’s had four children and nursed all of them, “Hey, how’s breastfeeding going? I have some things that I could tell you about that.” It’s ludicrous, because what do I know, compared to this mother who’s nursed all her children? But it’s sort of the thing you get used to talking about. You’re still learning over the course of a year. It’s that levity in that moment that makes a big difference, when you can just take a step back and say, “Well, isn’t this really ridiculous?” But the good news is that your patient is sitting on the bed and he just pooped himself, but I’m happy about that because he’s been constipated for four days. It brings a smile to everyone’s face.

DR. NICHOLAS ROWAN: Not infrequently, you hear that somebody sticks a bead in their ear, and typically the beads are little spheres and they act as a little suction in the ear canal, as you might imagine.

FA: That’s Dr. Nicholas Rowan — an ENT who has quite a lot of experience in the foreign object removal department.

NR: There’s plenty of people—God bless the general practitioners and pediatricians and ER doctors who try to get them out, who don’t have any specialized equipment, and then you encounter a wailing three-year-old in the emergency department with blood coming out of his ear, so a lot of these kids end up going to the OR to have things removed. You see a lot of bad things. I know the reason for the podcast can be sad, but one of these things are really terrible, like button batteries, which cause erosion of the esophagus or the airway, but if they eat a battery. Again, it’s probably a little too morbid to be discussing on the podcast, but I had this one kid who ate a bunch of Buckyballs. You know what those are? They’re little magnets that connect together and you can put them into a big ball, basically. This child ate a bunch of them, but the magnets didn’t stop working. They were in different spots in his intestine, and as they were being digested they all kind of Buckyballed together into this big sphere and ate through his intestine. That was pretty… pretty awful.

DR. SCOTT BADER: I’ve dealt with people who have gone into pediatrics, and then realize after a year or two of residency that it wasn’t the right field for them. People go into pediatrics because they love kids, but they don’t realize that they have to deal with parents; in fact, the parents will drive you crazy. If you can’t deal with that, you’re not going to find pediatrics enjoyable. The kids are the great part.

SB: I did my peds rotation, and it was inpatient. With outpatient, you don’t really get a sense of what outpatient peds is when you’re working in the hospital. The attending was like that one bad attending. Usually the attendings in peds are pretty benign, but he was just not a nice guy. He really made me question whether I wanted to go into pediatrics at all. I spent probably the rest of my entire third year looking at all these other different specialties. I knew it wasn’t surgery, but I looked at neurology, and I looked at psychiatry, and in each of the rotations, I would find myself still navigating back to dealing with kids. During the psychiatry rotation, I worked in the locked-down unit for the twenty worst teens in whatever county it was in. For urology, I did it with the pediatric urologist, and I kept navigating back to it. Eventually I realized that it was really not peds I didn’t like, it was the experience I had. Later on, I wound up confirming that with electives I took during my fourth year. Later on, myself, I went into some education. I explain to medical students as they come in, you’re going to make your decision about what you want to go into not based on whether you liked the attending or disliked the attending. You have to see yourself; you have to figure out what they do, what’s the bread and butter of this field, and then decide if that’s for you, what you see yourself doing for ten, twenty years.

EF: I knew I wanted to be a pediatrician, mostly because my entire life, people told me I acted more like a child than an adult. I figured that’d be the appropriate specialty for me as I was going into medicine. I was a counselor for a college at this wonderful camp called Camp Kesem, which is a camp for healthy children whose parents have cancer. Being a camp counselor for them over the course of four years of college, and then a year of medical school where I helped run the teen program. That really opened my eyes to how much I enjoy working with kids and how much they have to offer—how brilliant they were in their way, and how much they added to the world through their eyes. We had never appreciated as adults, just because we get so set in our ways. I worked my way through medical school with the idea that I wanted to go into pediatrics. I was taken aback by how fun a specialty it is. Obviously, medicine is a very serious undertaking, and every day I take my job very seriously. I approach every new case with the utmost respect for the patient, but there’s no doubt that kids are just fun. There’s a view of pediatricians as goofy doctors who have toys on their stethoscopes. I have a light … on my stethoscope — who wear goofy ties and goofy socks, dance in the hallway with their patients, sing a few songs in the next room, and then sit down and talk to everybody about poop all day, every day. I think it’s all very true. Pediatricians are extremely hardworking people who just know that even in the darkest of times, there needs to be humor, levity, and light, and are willing to put that spin on medicine. They just go to work every day with a smile on their face knowing that, hey, I get to hang out with children today, and that’s all.

LA: I’ve had an animal badge. The monkey is the one I go for, but ever since medical school, thinking back, it’s like of course I was peds because I’m walking around with a frog and a monkey on my badge. But I’m dealing with adults, and it’s like, hi! I’m Lauren, the doctor! They’re not so happy as the children are. But it was in cardiothoracic surgery in my third year, and my attending is one of the serious, typical—if he asks you a question, you don’t say, “Umm…” You answer, or you say, “I will find out for you.” Those are the two options, and your answer better be right. So he calls me—I wasn’t scrubbed in that surgery—but he calls me, “Lauren, come over here.” I go over to him, and like I said, I’m not in scrubs, so I’m not sterile, so I’m just peeking over, inching over to whatever he wanted me to look at without breaking sterility. He called me over there and said, “Take that stupid monkey off your badge.” I was like I had just had my ears scrubbed, and I was like, OK. Just like, pouted.

FA: It’s nice to know you’re allowed to be human, a little bit more than the other specialties.

LA: Exactly.

EF: One of the things I love about pediatrics is that kids force us to be human. Children do not subscribe to the “I’m sick, I’m a patient, I’m unwell, and I’m in this medical institution, so the whole atmosphere around my life must change.” Kids are going to be kids, in or outside the hospital. I think that really resonates with us as providers because the best way to treat a child is, yes, medication helps sometimes, yes, IV fluid helps sometimes, but sitting down with a kid, playing Legos with them, or pushing them down the hall in a toy car, or just picking them up and singing to them when they’re having trouble falling asleep, that means more to these kids than anything that we can offer them medically. The psychological impact of these children on us as providers is as if they’re saying, “Hey, I know I’m sick, but I’m still a kid; will you please still treat me like a child.” It makes such a difference. I think there is a lot of humanism, and it certainly reflects in everything we do. We don’t wear white coats, we don’t wear ties, a) because the kids don’t like them and make them nervous about us, b) it’s probably ineffective dress, but c) it just doesn’t really feel very pediatric to create that sort of barrier between you and your patients. Every day we find ourselves walking into a patient’s room and singing Frozen with them, just playing with them on every single television in the hospital at all times, talking to children about their favorite Toy Story movie, sitting down and playing Lego adventures with the kids for five minutes, just to bond with them. I talked with one of my teenage patients who I admitted yesterday about why the Cleveland Cavaliers were the worst team on the planet since LeBron James retired, so the families just think I’m wonderful. There’s a lot of good in that because the patients really change medicine for us in a very important way—to remind us every day that we’re dealing with people. I think a lot of times, it can get lost in thinking that medicine is about treatments and technology and advocacy and policy and politics, but it’s not. It’s about patients, and children, God love them, never let us forget that it’s about them, and that’s wonderful.

LA: When I make a point to introduce myself—and I don’t like to, in front of the kids—be like “I’m Dr. Appell. “ I’m more like “I’m Lauren Appell, I’m your doctor!” In peds, I thought I was always going to wear my white coat like it’ll help me establish the role of the doctor, and what I’ve learned is that I’m here for the kids, and the kids are scared when you walk in with a white coat. Everyone in peds wears jeans, so I wore red jeans to work today. I sit on the floor and pretty much let my patients examine me as much as I’m examining them. I’m there as their doctor and I have this fund of knowledge from school that I paid lots of money to learn, but also because I like taking care of these kids.

FA: I love how you introduced yourself as Dr. Nick.

NR: Oh, yeah, totally. Half of the battle of dealing with kids is that you have to bring yourself to their level. I mean you have to play their game. You can’t say, “Hey, I’m going to investigate your external auditory meatus now,” or “I’m going to listen to your oral pharynx.” You say, “Hey, you have any potatoes in your ear? Because I need to find out if there are any potatoes, so let me look. Did you put any potatoes in your ear before you came in?” If I told a kid, “Listen, pal, I’m going to take a three-foot-long scope and I’m going to stick it in your nose and then down your throat, and I’m going to have you awake throughout the entire thing”—this kid, regardless of his age, is going to say, no way. But when you say, “Hey, I’m going to make your boogers a movie star,” they’re much more inclined to figure out what you’re selling them.

JG: I don’t like anything about doctors. I like, I like only playing at doctor. FA: Did you have to go to the doctor to get it out?JG: Yeah!FA: Was the doctor nice?JG: No.FA: No. Was he mean?JG: No, the doctor was nicer, but the tweezers were mean.FA: Oh, the tweezers were mean. Ow.JG: I did, it hurted to get out the tweezers. Mama hold onto my …22:22 FA: Oh, that’s nice! Was it scary for you, Mom?ASG: Oh! It was—it was not fun, yeah. It was a very late night.JG: It was not fun!ASG: They couldn’t get it out in the ER—JG: IT WAS NOT FUN!ASG: —and we had to go back in the morning, right?JG: It was not fun!

NR: Just a couple weeks ago, was this kid. He came in, he had been eating with his mom, and his mom were out celebrating a good report card or something like that, I forget what. They went out and they were having chicken parm at this Italian restaurant. Chicken parm: it’s their thing. Shortly after housing his chicken parm, he started to develop some nausea, vomiting, and he said it was hard to swallow and it felt like something stuck in his throat. After about half a day, he’s still really uncomfortable, his stomach is hurting and he’s nauseous, and maybe had a little difficulty swallowing his own spit, so she brings him to the emergency room. I go and see him in the morning, and he was relatively comfortable, but shortly after I see him, he became uncomfortable again and started having this vomiting thing and he wasn’t able to swallow any of his secretions, so at that point I’m kind of obligated to take somebody to the operating room and at least have a look around, look in their airway, look in their esophagus, look in their stomach, take a peek at what’s happening. So we took him to the OR, and we stuck a scope in his esophagus, and I looked in and I saw something I’d never really seen before in somebody’s throat. It looked like a little piece of meat. So I reached in with a long forceps and started pulling it out. Sure enough, it was a piece of meat. I thought, hmm, this is interesting. I look back in, and I pull out more, and I look in and I pull out more and I see a piece of cheese. So now the diagnosis is chicken parm in the esophagus. We resumed pulling out chicken parm from this child’s throat for about the next 45 minutes. He was basically impacted with chicken parm from the top of his throat all the way down to his stomach. The best part of the story was that, as surgeons, we pride ourselves on having really strong stomachs, so we see lots of gross stuff, lots of pus, lots of spit, lots of snot, lots of things that gross people out. This was the one time where I had ever seen an attending get sick. About two minutes into biopsying this mass, because we weren’t sure what it was yet, I hear this “augh!” Dry heaves coming from the attending being grossed out by probably two feet of chicken parm impacted in somebody’s esophagus. It was pretty nasty, but pretty rewarding at the same time, to be honest.

LA: It was my very first rotation of medical school, my third year, my clinical rotation. I started off, I was like, good, I’m going to get this over with, it’ll be eight weeks and I’ll be done, and I’ll be on to adult medicine. I remember one of the first patients I had was bronchiolytic and I remembered seeing this kid in the ER, and I’m like, my gosh, this kid’s really sick, and then coming back there at five, doing my rounds this morning, and he’s bouncing all over the crib, much more interactive, much more playful and I was just like, I think I like this. That’s when I knew I wanted to be a pediatrician. I never thought—I never liked to babysit, I never liked taking care of other people’s children, having to watch over them, but man, it’s really endearing when you have a really sick kid. Even the not-so-sick ones are so innocent. I don’t have to undo years and years of damage that they’ve done to themselves. I was getting jaded toward the end of medical school about adults and the population we cared for at the hospital. Being kids, and when they come in, and they’re so sick, and then you see them a day later and you’ve gotten some fluids in them, and they bounce back, and they’re bouncing around the room—it’s really rewarding to be able to see that what you do makes a difference.

EF: I remember specifically I was taking care of one patient who was very sick. It was actually during my fourth year of medical school. He was a 12-month-old and had hepatoblastoma, which is a very rare form of liver cancer. His parents were rightfully terrified, and I just remember over the course of those couple weeks they were there, starting chemotherapy, this 12-month-old, without even really being able to speak, displayed more grit, and emotion, and tenacity than I think I’ve ever seen. He was so ill-appearing when he came in, and over the course of IVs and medications and first doses of chemotherapy, he would literally grit the couple of teeth he had and allow the nurses to do what they had to do. Every day that passed, he would just sit up and let us listen to him. He’d been crying more in the last hour or two because he’s miserable and nauseated and vomiting. His parents—I just remember the look in their eyes every single day when we would walk in and they would say, “Thank you so much for taking care of our baby. This is so difficult, and it makes it so much better, knowing that we have people who care about him and care about us.” Appreciation from parents and families is really what makes our job meaningful, second only to seeing the children get better, knowing that we have done our small part in helping restore a family’s health and sanity. Just knowing that they can go home in the next day and enjoy their time together, rather than worrying about the health of their child, or at least worrying less about the health of their child, makes every day so meaningful to us.

FA: After talking to these doctors for this episode, I found myself wondering if there are things all doctors can learn from Pediatrics and apply to their own fields. At the end of the day — no matter our age, and whether we’re doctors or patients — aren’t we all just as deserving as children when it comes to receiving love, comfort and reassurance? Being told that someone will be watching over us as we drift off to “sleep” for a big surgery, and that they’ll be there for us when we wake up? While we adults are far more adept at things like walking, reading and tying our shoelaces, I think we can actively learn more from children: How to be fully in the moment, to be open to one another, and to really, truly connect.

Thank you to Jesse Gellert and Doctors Lauren Appell, Nicholas Rowan, Eli Freiman and Scott Bader; the My First Cadaver Team, Papa Claire Music & Compulsion Music; our Nerf-blasting friends from Salted Stone; and special thanks to Robert Meekins, who is not a doctor. Stay tuned for Episode 12—the final episode of Season 1! Thank you so much for listening! If you like us, please rate us on iTunes, follow us on Facebook, and share your thoughts with us on our blog. And remember, guys: In all seriousness, please keep small objects like button batteries, toys with small parts, and especially coins out of the reach of children. Kids are irrational little aliens — don’t tempt them with shiny objects. You heard Doctor Nick.

JG: I want, I wanna, I wanna be in that play. I want, I wanna be on stage. I wanna be on stage.FA: What character would you want to play?JG: I want, I wanna be, I wanna be... Momma: Who's in Alexander Hamilton? ASG: You want to be Alexander Hamilton? Is that who you want to be?JG: Yeah.